Bile Acid Malabsorption Diagnosis and Management

Classification and Pathophysiology

The European Society of Gastrointestinal Endoscopy recommends that Type 1 (Secondary BAM) be considered in patients with ileal disease or resection, which occurs in more than 80% of patients following ileal resection 2
The British Society of Gastroenterology notes that Type 2 (Primary BAM/Idiopathic) may be related to defective production of Fibroblast Growth Factor 19 (FGF19), which normally inhibits hepatic bile acid synthesis 3
The American Gastroenterological Association states that Type 3 (Secondary to other conditions) is associated with conditions such as post-cholecystectomy, small intestinal bacterial overgrowth, celiac disease, or radiation enteropathy 4, 5

The National Institute for Health and Care Excellence (NICE) guidelines suggest that chronic watery diarrhea, often worse after meals, is a common symptom of BAM 5
The American College of Gastroenterology recommends that a 75Se-HCAT (SeHCAT) scan be used as the gold standard for diagnosis where available, with values less than 15% suggesting BAM 8, 2, 3
The European Society of Gastrointestinal Endoscopy notes that an empiric therapeutic trial with bile acid sequestrants is appropriate, particularly if fecal calprotectin is not significantly raised 2

The American Gastroenterological Association recommends that first-line treatment is with bile acid sequestrants, such as cholestyramine, which is effective but may be unpalatable 1, 2
The British Society of Gastroenterology suggests that alternative sequestrants, such as colestipol or colesevelam, can be used for patients who don't tolerate cholestyramine 2
The National Institute for Health and Care Excellence (NICE) guidelines recommend that dietary modifications, such as a low-fat diet, may help reduce symptoms, and that loperamide can be used as an adjunctive treatment 6, 2

The American College of Gastroenterology states that post-ileal resection patients should be considered for a therapeutic trial of bile acid sequestrants, as BAM occurs in >80% of patients following ileal resection for Crohn's disease 2, 1
The European Society of Gastrointestinal Endoscopy notes that small intestinal bacterial overgrowth often coexists with BAM and may require separate treatment 2, 8
The American Gastroenterological Association recommends that BAM should be considered in patients with IBS-D symptoms with atypical features, such as nocturnal diarrhea or prior cholecystectomy 7